September 08, 2013

A memo to the Saudi Minister of Health

Your media relations staff are doubtless keeping you informed on MERS coverage both in the Kingdom and around the world. If so, you are aware that some reports are critical of the way MERS cases have been announced—or not announced, as the case may be. Your extensive foreign experience, especially in Canada, has shown you how the Western media, in particular, cover disease outbreaks, and how our medical authorities also come under criticism from time to time.

Such criticism (and not only on health issues) has inspired a large body of information on crisis communications—conveying what the public needs to know to protect itself in an emergency. Again, as health minister you are doubtless aware of the principles of such communications, and the tight linkage between politics and healthcare.

However, your ministry's response to the continuing outbreak of MERS-CoV suggests that your officials have not taken those principles to heart, or implemented them as policy.

A key principle is that the best defence is a good offence: that is, tell the truth, tell it often, and tell it well. Withholding information that might seem embarrassing, or likely to cause panic, is tempting but very dangerous.

A defensive adviser may argue that critics can't attack you over facts they don't know. And you certainly don't want to compound an outbreak problem with panic—whether among your public or your healthcare professionals. But journalists know that when there is no story, that becomes the story. And they also know that efforts to cover up invariably become a bigger problem than the original problem itself.

Official silence, or only partial disclosure, gets a government nowhere. Consider the Cubans, who enjoyed a deserved reputation as battlers against cholera in Haiti. But since the disease turned up in Cuba last year, the government has admitted almost nothing, and still keeps official reports out of the state-controlled media. Obviously this hasn't worked: the government is discredited both domestically and internationally, cholera continues to spread, and no one is any better off.

Your government, Minister, now risks a similar problem. Both medical experts and the media are growing impatient at the erratic flow of information on MERS, and I hear rumours that Saudi hospital staff are as alarmed as those in Canadian hospitals afflicted with SARS ten years ago. And well they might be, when this virus seems to thrive in healthcare settings.

An aggressive, open communication policy is now urgently called for. Rather than indulge in a litany of past problems, I would like to recommend some steps your ministry could take right now to ease concerns around the world while also ensuring solid support from Saudi professionals and public.

1. Frame a detailed, standard format for reporting each case. At a minimum, this should include:

• the age, gender, and occupation of the patient;

• mention of specific underlying medical conditions, if any;

• place and date of onset;

• a description of treatment and place of treatment;

• the specific relationship, if any, to previous cases;

• tests administered and results of those tests;

• if possible, a statement by a Ministry spokesperson putting this case in the context of recent events.

Each case should be announced when the suspicion of MERS arises, and mentioned again when test results are known and when the patient recovers or dies. On occasion, a more detailed account may help to explain what is being learned about the disease, or why a particular case has developed in an unusual way.

2. Give the struggle against MERS a human face and official voice. In China, Dr. Zhong Nanshan has ably served as an authority against SARS, H5N1, H1N1, and now H7N9. His blunt statements do not disturb; they reassure the Chinese public that he is being honest with them. When he has good news, it is trusted.

In the Kingdom, Dr. Ziad Memish has already assumed this role to a certain extent. He has great credibility with his colleagues around the world, and his scientific papers on MERS are read attentively. His posts to ProMED-mail have been welcomed. He can do more.

But I suggest you yourself could serve in that role as well. For example, the MOH Corona website includes a statement by you on the MERS outbreak—but it was published in May. A regular weekly statement, summarizing events and sharing your thoughts, would both update the public and boost confidence that your ministry is in control and doing its utmost. Regular press conferences with the Saudi and international media would be another wise step.

3. Improve the information content of your MERS site, in both Arabic and English. On the MOH portal, you yourself say in your Minister's Message, "Use of the Internet allows us to exchange information at high volumes and speeds across all traditional geographic boundaries. ... At MOH, we seek to strengthen our relationship with the public by focusing on patient education, program information, health-related articles and interviews."

Those are precisely what the English-language site lacks, and that is why people around the world, concerned about MERS, are coming away feeling frustrated and uncertain about what exactly is going on, and what is being done about it. It is simply not enough to announce a death or recovery when the case itself has never been mentioned before.

As an example of how it could be done, please consult the website of CIDRAP at the University of Minnesota. It combines both breaking news and permanent features, including an excellent MERS-CoV Resource List—with links to the MOH MERS-CoV page. With a more technical approach oriented to health professionals, ECDC's website is still accessible to non-specialist readers.

I realize that these suggestions are both simple and difficult to implement. They require a clear policy, effectively implemented by trained communications experts with solid political backing from you and your government. But public health, like justice, must not only be done; it must be seen to be done.

Rest assured that people around the world sincerely want the Kingdom of Saudi Arabia to overcome this mysterious disease, and to point the way for the rest of us. Since you are the leader of the effort against MERS, you can tell us how that effort is going. We wish you every success.

Comments

Your media relations staff are doubtless keeping you informed on MERS coverage both in the Kingdom and around the world. If so, you are aware that some reports are critical of the way MERS cases have been announced—or not announced, as the case may be. Your extensive foreign experience, especially in Canada, has shown you how the Western media, in particular, cover disease outbreaks, and how our medical authorities also come under criticism from time to time.

Such criticism (and not only on health issues) has inspired a large body of information on crisis communications—conveying what the public needs to know to protect itself in an emergency. Again, as health minister you are doubtless aware of the principles of such communications, and the tight linkage between politics and healthcare.

However, your ministry's response to the continuing outbreak of MERS-CoV suggests that your officials have not taken those principles to heart, or implemented them as policy.

A key principle is that the best defence is a good offence: that is, tell the truth, tell it often, and tell it well. Withholding information that might seem embarrassing, or likely to cause panic, is tempting but very dangerous.

A defensive adviser may argue that critics can't attack you over facts they don't know. And you certainly don't want to compound an outbreak problem with panic—whether among your public or your healthcare professionals. But journalists know that when there is no story, that becomes the story. And they also know that efforts to cover up invariably become a bigger problem than the original problem itself.

Official silence, or only partial disclosure, gets a government nowhere. Consider the Cubans, who enjoyed a deserved reputation as battlers against cholera in Haiti. But since the disease turned up in Cuba last year, the government has admitted almost nothing, and still keeps official reports out of the state-controlled media. Obviously this hasn't worked: the government is discredited both domestically and internationally, cholera continues to spread, and no one is any better off.

Your government, Minister, now risks a similar problem. Both medical experts and the media are growing impatient at the erratic flow of information on MERS, and I hear rumours that Saudi hospital staff are as alarmed as those in Canadian hospitals afflicted with SARS ten years ago. And well they might be, when this virus seems to thrive in healthcare settings.

An aggressive, open communication policy is now urgently called for. Rather than indulge in a litany of past problems, I would like to recommend some steps your ministry could take right now to ease concerns around the world while also ensuring solid support from Saudi professionals and public.

1. Frame a detailed, standard format for reporting each case. At a minimum, this should include:

• the age, gender, and occupation of the patient;

• mention of specific underlying medical conditions, if any;

• place and date of onset;

• a description of treatment and place of treatment;

• the specific relationship, if any, to previous cases;

• tests administered and results of those tests;

• if possible, a statement by a Ministry spokesperson putting this case in the context of recent events.

Each case should be announced when the suspicion of MERS arises, and mentioned again when test results are known and when the patient recovers or dies. On occasion, a more detailed account may help to explain what is being learned about the disease, or why a particular case has developed in an unusual way.

2. Give the struggle against MERS a human face and official voice. In China, Dr. Zhong Nanshan has ably served as an authority against SARS, H5N1, H1N1, and now H7N9. His blunt statements do not disturb; they reassure the Chinese public that he is being honest with them. When he has good news, it is trusted.

In the Kingdom, Dr. Ziad Memish has already assumed this role to a certain extent. He has great credibility with his colleagues around the world, and his scientific papers on MERS are read attentively. His posts to ProMED-mail have been welcomed. He can do more.

But I suggest you yourself could serve in that role as well. For example, the MOH Corona website includes a statement by you on the MERS outbreak—but it was published in May. A regular weekly statement, summarizing events and sharing your thoughts, would both update the public and boost confidence that your ministry is in control and doing its utmost. Regular press conferences with the Saudi and international media would be another wise step.

3. Improve the information content of your MERS site, in both Arabic and English. On the MOH portal, you yourself say in your Minister's Message, "Use of the Internet allows us to exchange information at high volumes and speeds across all traditional geographic boundaries. ... At MOH, we seek to strengthen our relationship with the public by focusing on patient education, program information, health-related articles and interviews."

Those are precisely what the English-language site lacks, and that is why people around the world, concerned about MERS, are coming away feeling frustrated and uncertain about what exactly is going on, and what is being done about it. It is simply not enough to announce a death or recovery when the case itself has never been mentioned before.

As an example of how it could be done, please consult the website of CIDRAP at the University of Minnesota. It combines both breaking news and permanent features, including an excellent MERS-CoV Resource List—with links to the MOH MERS-CoV page. With a more technical approach oriented to health professionals, ECDC's website is still accessible to non-specialist readers.

I realize that these suggestions are both simple and difficult to implement. They require a clear policy, effectively implemented by trained communications experts with solid political backing from you and your government. But public health, like justice, must not only be done; it must be seen to be done.

Rest assured that people around the world sincerely want the Kingdom of Saudi Arabia to overcome this mysterious disease, and to point the way for the rest of us. Since you are the leader of the effort against MERS, you can tell us how that effort is going. We wish you every success.